CASE STUDY

Observational Management Of Suprachoroidal Hemorrhage

Three cases of massive hemorrhage that resolved with observation

ALEXANDER WEISS, BA • CHRISTOPHER R. HENRY, MD • HARRY W. FLYNN, JR., MD

Suprachoroidal hemorrhage (SCH) can be a devastating complication of intraocular surgery. Massive SCH, also called “kissing” or appositional SCH, can occur intraoperatively or as a delayed complication of intraocular surgery, and it is generally associated with poor visual outcomes.¹

The pathophysiology of SCH is not completely understood, but one hypothesis is that fluctuating intraoperative ocular pressure precipitates a serous effusion into the suprachoroidal space.

Subsequently, sclerochoroidal separation and concomitant rupture of the long or short posterior ciliary arteries occur.^2,3 The diagnosis of SCH is clinical, characterized by severe ocular pain, darkening of the red reflex, and a firm globe.

We describe here three cases of SCH, two of which occurred intraoperatively during phacoemulsification and one of which developed in a delayed fashion, following placement of a glaucoma-drainage implant in the setting of previously failed trabeculectomy. In all of the cases, the decision was made to manage these patients with observation alone.

CASE REPORTS

Case 1

An 80-year-old woman taking clopidogrel bisulfate (Plavix, Bristol–Myers Squibb, New York, NY) presented at the retina clinic two days following phacoemulsification and IOL implantation, complicated by massive SCH in the left eye.

On examination, the patient’s BCVA was 20/25 in the right eye and hand motion in the left eye. IOP was 16 mm Hg in the right eye and 18 mm Hg in the left eye. A relative afferent pupillary defect was visible in the left eye.

Slit-lamp microscopy of the left eye demonstrated temporal displacement of the IOL, microcystic corneal edema, and a prominent SCH in an appositional configuration posterior to the IOL (Figure 1A). The patient was maintained on topical prednisolone acetate 1% ophthalmic drops four times daily and dorzolamide 2%/timolol 0.5% ophthalmic drops (Cosopt, Merck & Co., Whitehouse Station, NJ) two times per day in the left eye.

Figure 1. External photograph (A) of the patient’s left eye, demonstrating kissing SCH posterior to the IOL. Photo montage (B) of the fundus at three-week follow-up, showing dramatic reduction in the size of the SCH. Photo montage (C) of the fundus at five-week follow-up, showing retinal folds and persistent SCH in the inferior parts. Completely resolved SCH (D) with retinal folds.

At the three-week follow up visit, the BCVA had markedly improved to 20/80 in the left eye. Dilated fundus examination demonstrated a substantial reduction in the size of the SCH (Figure 1B). We noted improved centration of the IOL as well.

By the five-week follow-up, BCVA improved to 20/50, and examination of the fundus demonstrated retinal folds overlying persistent SCH in the inferior parts. The macula was attached but exhibited a pigmentary line through the fovea (Figure 1C). The patient was tapered off the topical prednisolone acetate 1% drops.

Ten weeks after presentation, the SCH had completely resolved, but retinal folds remained (Figure 1D). The patient remained stable with observation, and at the 18-month follow-up, BCVA was 20/60. The fundus appeared stable with RPE changes within the macula. IOP was 15 mm Hg in the right eye and 16 mm Hg in the left, and the patient no longer required topical drops.

Case 2

An 81-year-old woman with a history of primary open angle glaucoma presented one week after a cataract extraction surgery complicated by an intraoperative SCH in the right eye. Due to the abrupt onset of hemorrhage, the anterior-segment surgeon did not implant an IOL, and the patient was left aphakic.

Indirect ophthalmoscopy revealed a large SCH (Figure 2A). Using an 11+ D lens, the BCVA was remarkably 20/40 in the right eye and 20/20 in the left. IOP was 21 mm Hg in the right eye. We treated the patient with topical prednisolone acetate 1% ophthalmic drops eight times daily, atropine 1% ophthalmic drops three times daily, and dorzolamide 2% ophthalmic drops (Trusopt, Merck) twice daily in the right eye.

Figure 2. Indirect ophthalmoscopy (A) of large SCH and five-month follow-up (B) showing completely resolved SCH.

The SCH slowly resolved over several months, and the patient received a secondary IOL 12 months following the original cataract surgery (Figure 2B). At the 36-month follow-up, her BCVA was 20/50, and IOP was 14 mm Hg.

The patient remained on topical dorzolamide 2% ophthalmic drops twice daily and latanoprost 0.005% (Xalatan, Pfizer, New York, NY) ophthalmic drops once nightly for the management of primary open angle glaucoma.

Case 3

A 76-year-old man with primary open angle glaucoma and a history of failed trabeculectomy presented 11 months following the placement of a Baerveldt glaucoma implant (Abbott Medical Optics, Santa Ana. CA), with a chief complaint of flashes and a nasal visual defect in the right eye.

The patient had undergone a triamcinolone acetonide intravitreal injection (Kenalog, Bristol–Myers Squibb, New York, NY) three months prior to presentation for the management of postoperative CME, but he denied any other antecedent factors. His BCVA at presentation was 20/100 in the right eye and 20/25 in the left. IOP was 14 mm Hg in the right eye and 15 mm Hg in the left.

Dilated fundus examination revealed a localized temporal SCH in the right eye (Figure 3A). B-scan echography revealed mild to moderate vitreous opacities, with a temporal bullous SCH extending posterior to the equator.

Figure 3. Dilated fundus examination (A), revealing a localized temporal suprachoroidal hemorrhage. Dilated fundus examination (B) showing RPE changes in the area of prior SCH.

We managed the patient with observation, and the SCH resolved over a six-week period, when his BCVA improved to 20/40. Dilated fundus examination at that time revealed RPE changes in the area of the prior SCH (Figure 3B). At the 36-month follow-up, BCVA remained stable at 20/40, and IOP was 18 mm Hg.

DISCUSSION

Suprachoroidal hemorrhage has been documented as a potential complication of cataract surgery for years. Baron de Wenzel, in his landmark 1786 treatise on cataract surgery, first described this catastrophic complication as a harbinger of poor visual prognosis.⁴

Both systemic and ocular conditions may predispose patients to SCH. In their case-control analysis, Moshfeghi and colleagues found that increasing age and a history of pars plana vitrectomy significantly correlated with the development of appositional SCH.⁵ Additional studies have reported increased axial length, glaucoma, aphakia, and atherosclerosis as risk factors for the development of perioperative SCH.^4-6

Suprachoroidal hemorrhage has occurred intraoperatively or postoperatively following trabeculectomy, glaucoma drainage device implantation, cataract surgery, secondary IOL placement, penetrating keratoplasty, pars plana vitrectomy, and scleral buckling, among other procedures.^4-8

While current small-incision surgical techniques have reduced the incidence of this complication, the reported risk of developing SCH during cataract extraction is nevertheless 0.03% for phacoemulsification, compared to 0.13% with traditional extracapsular cataract extraction.^8,9

A History of Difficult Management

The management of massive SCH can be challenging. Apposed retinal tissue raises concern of irreversible damage, and surgery is often advocated in these instances, particularly in the setting of vitreous incarceration, retinal incarceration, or associated retinal detachment.^3,6,10

Chu et al used echography to follow 18 patients with massive SCH and found that the mean duration of retinal apposition in their series was 15 days, and the mean time to clot lysis was 14 days.¹¹

In their series of 106 patients with SCH, Reynolds and colleagues described the results of 20 patients with appositional SCH. Of these patients, 13 underwent a secondary procedure of a drainage sclerotomy with or without pars plana vitrectomy. Six of these 13 (46%) eyes had improved visual acuity of better than 20/200, compared to zero of seven (0%) eyes that were managed with observation alone.

Welch and colleagues reported the outcomes of 30 eyes suffering from massive SCH during cataract surgery.¹² They managed with initial observation six of 13 patients with vitreous loss but no retinal detachment at the time of surgery. Of these six patients, five (83%) went on to develop retinal complications, including rhegmatogenous retinal detachment (two eyes), retinal tears (two eyes), and CME (one eye).

Seven of the 13 patients with vitreous loss but no retinal detachment, at the time of surgery, underwent a secondary surgical procedure. A retinal detachment developed in only one of the patients undergoing a secondary surgical procedure, and five of seven (71%) did well, with BCVA of 20/200 or better.

In contrast, Scott et al reviewed 51 cases of kissing SCH.¹³ They were stratified into intraoperative, postoperative, and traumatic SCH cohorts. The authors’ data, as a whole, revealed no significant difference in visual outcomes between observed and operated patients. They did find, however, that apposition of more than 14 days was associated with inferior visual acuity outcomes.

Other predictors of a poor visual outcome in their series included vitreous incarceration, concurrent or delayed retinal detachment, and the presence of an afferent pupillary defect.

Wirostko and associates reported on 48 patients undergoing surgical drainage of SCH. They devised a classification scheme according to the severity: (1) nonappositional SCH without vitreous or retinal incarceration; (2) centrally appositional SCH without vitreous or retinal incarceration; (3) SCH with vitreous incarceration; and (4) SCH with retinal incarceration.¹⁴

Factors associated with a worse visual prognosis in their series included retinal incarceration and/or retinal detachment at presentation.

CONCLUSION

Retinal physicians should decide on the management of SCH on an individual-case basis. They may consider an observational approach initially in select cases. Appositional SCH, though appearing daunting on imaging, may spontaneously resolve with good visual outcomes. RP

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